Section 4 Plastic and Reconstructive Problems

TR I NDADE DE ALME I DA ET AL

reconstituting onabotulinumtoxinA with 2% lido- caine with 1:200,000 epinephrine.

Bupivacaine

Yen and colleagues 42 conducted a randomized, double-blind study with 16 patients treated for glabellar furrows. OnabotulinumtoxinA reconsti- tuted with 0.75% bupivacaine was injected into one corrugator, and the contralateral muscle received the same product reconstituted with unpreserved saline. At 1 week, the side treated with bupivacaine- reconstituted toxin showed greater muscle weakness. At 1 and 3 months, there were no differences between the sides. They concluded that bupivacaine did not affect efficacy or duration of onabotuli- numtoxinA but could result in a less-painful procedure. They attributed the faster onset of the paresis to a possible synergistic effect of bupivacaine- induced myotoxicity. Bigalke and colleagues 44 demonstrated that human albumin supplementation of abobotulinumtoxinA could allow a dose reduction without decrease of therapeutic efficacy. In another study, 45 106 patients were treated with abobotulinumtoxinA (diluted in 0.1% albumin solution to a concentration of 25 U/mL) over 5 to 10 years for cervical dystonia, blepharospasm, and hemifacial spasm. The conclu- sion was that long-term treatment with albumin- supplemented BoNTA was safe, effective, and could help reduce costs. To evaluate the stability of fragments of BoNTs (light chain and the binding domain of the heavy chain) in response to mild agitation, Toth and colleagues 46 performed several in vi tro tests. They used endo- genous trypsin-like protease to cleave the 150-kDa toxin into a 50-kDa N-terminal light chain (Lc) and a 100-kDa C-terminal heavy chain. The latter was further proteolyzed into a 50-kDa N-terminal Foam During Reconstitution Sterile Water BoNTA will work if dissolved in sterile water, but this causes intense short-lived pain at the injection site. 43 Albumin

Recently, a brief communication described the injection of a ‘‘cocktail’’ composed of abobotuli- numtoxinA, 2% lidocaine with 1:100,000 epineph- rine, and hyaluronic acid (Perlane, Medicis, Scottsdale, AZ) for rejuvenation of the upper face. To mix all products, two syringes were connected, and at least 10 back-and-forth mixings were performed. The combined product was injected into five patients in the periocular and glabellar areas in linear threads, small boluses, or serial punctures, and the author concluded that there was no compromise in efficacy or safety. 36 Another study compared side by side, in 29 patients, onabotulinumtoxinA reconstituted in 2% lidocaine with normal saline for axillary hyperhidrosis. 37 They concluded that it was equally effective over the short and long term. Because injections with lidocaine- reconstituted onabotulinumtoxinA were associated with significantly less pain, it might be preferable for treating axillary hyperhidrosis. There has been a report of a fatal case of anaphylaxis after the injection of an onabotulinumtoxinA and lidocaine mixture in a woman for chronic neck and back pain. 38 It was not possible to establish which drug was responsible for the reaction, but when using lidocaine to dilute BoNTA, it is advisable to consider that it may increase the possibility of an anaphylactic reaction. Hantash and Gladstone tested the effect of epinephrine 1:100,000 on onabotulinumtoxinA efficacy. 39 Fourteen subjects were treated and eval- uated for up to 6 months. The authors concluded that epinephrine might accelerate the rate of onset of action and enhance the short-term efficacy of onabotulinumtoxinA for the treatment of periorbital rhytides. Other articles reporting authors’ personal experience 40,41 have recommended the addition of epinephrine to saline for the reconstitution of abo or onabotulinumtoxinA.

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